Background: Nausea is one of the most commonly reported side effects in patients receiving chemotherapy. Patients who experience nausea during chemotherapy may also experience depression, metabolic imbalances, dehydration, decreased ability to function, and treatment delays, which can ultimately affect outcomes.
Objectives: This study aimed to determine the efficacy of a cool damp washcloth with peppermint essential oil versus a cool damp washcloth alone on the self-reported intensity of nausea in patients receiving chemotherapy in the outpatient ambulatory setting.
Methods: 79 adult patients receiving chemotherapy were recruited from an outpatient ambulatory infusion center in the southeastern United States. Patients were separated into two groups (no scent and peppermint) and asked to rate the intensity of their chemotherapy-induced nausea at pre- and postintervention using the Baxter Retching Faces pictorial scale.
Findings: The results demonstrated that the use of peppermint oil was effective in decreasing the intensity of nausea experienced by patients compared to a cool washcloth alone.
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In patients receiving certain or selected chemotherapies, nausea can be a common side effect, and patients who experience nausea as a result of chemotherapy treatment may suffer from decreased quality of life. Patients with cancer who suffer from decreased quality of life as a result of chemotherapy-induced nausea and vomiting (CINV) may also experience depression, metabolic imbalances, dehydration, unexpected office visits, decreased ability to function, and treatment delays, which can affect outcomes and their response to chemotherapy treatment (Harrison et al., 2016; Navari & Aapro, 2016). Research has shown that patients who receive chemotherapy report that CINV is one of the most anxiety-producing, distressing, and feared symptoms of chemotherapy treatment (Ng et al., 2015). Because nausea is a subjective symptom that is patient reported, whereas vomiting is an objective and measurable occurrence, Ng et al. (2015) suggest that clinicians should measure and report nausea as a separate outcome. The use of nonpharmacologic agents, such as ginger and cannabinoids, have not been shown to be effective and, despite advances in antiemetic medications, better methods are needed to manage nausea in patients with cancer (Ng et al., 2015).
In a 2012 systematic review, Lua and Zakaria found only five previously published studies on the use of aromatherapy in patients experiencing nausea and vomiting, with only one article on its use in patients receiving chemotherapy. Based on the literature reviewed, Lua and Zakaria (2012) suggested that these previous studies have methodologic flaws, citing limitations such as poor study designs, small sample sizes, and difficulty recruiting and retaining patients, indicating that additional research on this topic was necessary. According to Lua and Zakaria (2012), emphasis should be placed on integrating holistic care into the treatment plans of patients receiving chemotherapy, including the addition of complementary therapies such as aromatherapy, to help achieve desirable patient outcomes.
Aromatherapy is a common complementary and alternative medicine modality (Blackburn et al., 2017). According to Ferri (2017), aromatherapy is a form of herbal medicine, which uses various oils extracted from plants, trees, and shrubs, that can be administered through skin absorption or inhalation. The fragrant biochemical structures of certain herbs are believed to act in the areas of the brain related to past experiences and emotions and influence how some patients experience nausea (Ferri, 2017). In a 2011 study, Stringer and Donald reported using aromasticks scented with a blend of various essential oils to help alleviate anxiety, nausea, and sleep disturbances in patients receiving chemotherapy. The aromasticks used in Stringer and Donald’s (2011) study were individual nasal inhalers with an essential oil blend of two or more essential oils, such as peppermint. The majority of the study’s 160 patients were female, and 45 patients were receiving active treatment with chemotherapy and experiencing nausea. Of the 45 patients who used the aromasticks with an essential oil blend for CINV, 82% of patients reported an improvement in their symptoms following the intervention (Stringer & Donald, 2011). However, Stringer and Donald’s (2011) study did not compare the intensity of symptoms before and after using the aromastick, nor did it clearly define which aromatherapy blend was used for the patients with nausea.
Previous studies have suggested that inhaling peppermint essential oil can reduce nausea for postoperative patients. According to Briggs et al. (2016), patient reports on the use of peppermint oil in relieving postoperative nausea were overwhelmingly positive, and patients reported being willing to use aromatherapy again if they required additional surgical procedures. In a study by Lua et al. (2015), inhalation of ginger essential oil was examined in relation to CINV in women with breast cancer and their quality of life. Lua et al. (2015) found that administering ginger essential oil aromatherapy during a five-day period had little effect in reducing CINV; however, aromatherapy was found to be beneficial in patients with acute nausea. Joulaeerad et al. (2018) also studied the effects of peppermint essential oil on the severity of nausea and vomiting experienced by pregnant women, but no statistical difference was found in the use of the peppermint essential oil versus a placebo.
The purpose of this study was to evaluate the efficacy of using peppermint oil on a cool damp washcloth applied to the neck versus a cool damp washcloth with no scent in patients who reported chemotherapy-induced nausea. It is a standard nursing practice at the study institution to offer a cool damp washcloth to patients experiencing nausea and vomiting; therefore, a cool damp washcloth was used as experiential evidence in this study. Peppermint oil was selected because of its low risk for adverse effects when inhaled and because it has been previously identified as an essential oil that may ease gastrointestinal symptoms (National Association for Holistic Aromatherapy, 2017).
Sample and Setting
A convenience sample of patients was voluntarily recruited from the 75-chair Ambulatory Infusion Center (AIC) at the Winship Cancer Institute at Emory University in Atlanta, Georgia. Chemotherapy regimens and premedications varied among patients, but participation in this study did not interfere with or delay patients’ ordered treatment. Patients were asked to rate their current level of nausea, and the infusion nurse completed a preliminary screening for those who rated their nausea as a score of 4 or higher on a 6-point pictorial scale.
Patients who rated their nausea as 4 or higher were eligible for the study if they were aged 18 years or older, experiencing nausea or had a history of nausea with chemotherapy, and actively receiving a chemotherapy and/or biotherapy or immunotherapy regimen. Patients were ineligible for the study if they rated their nausea as 3 or less, were currently enrolled in a clinical trial, had a diagnosis of head and neck cancer, were aged 17 years or younger, or were receiving a chemotherapy regimen including oxaliplatin. Patients receiving oxaliplatin were excluded because exposure to cold or cold objects (e.g., cool damp washcloth) while taking oxaliplatin may lead to nerve problems or a worsening of existing nerve problems (Sanofi-Aventis, 2015). Patients also had to have a cancer diagnosis and reported an ability to smell. Patients who were only receiving supportive therapy, such as blood products, IV fluids, and growth factors; sensitive to or allergic to peppermint or spearmint; or a previous participant in the study were also excluded.
This study was approved by the Emory Institutional Review Board to conduct a randomized controlled trial evaluating the effectiveness of peppermint oil on a cool damp washcloth versus a cool damp washcloth alone in reducing nausea in patients receiving chemotherapy. Involvement in the study presented a potential confidentiality risk, which was mitigated by maintaining all study documents (e.g., data collection forms) in a secured area of the AIC. All precautions were taken to protect patient health information according to institutional review board guidelines. Patients were deidentified by using a unique identification number on the data collection sheet.
All patients admitted to the AIC were asked to rate their level of nausea using the Baxter Retching Faces (BARF) pictorial scale (Baxter et al., 2011). If a patient met the inclusion criteria, the study team was contacted to explain the purpose of the study and to obtain written informed consent. The study team was primarily comprised of direct care RNs working in the AIC. If a study team RN was caring for a patient with a BARF score of 4 or higher, he or she contacted another study team member to consent the patient, implement the intervention, and conduct a follow-up survey.
Once written informed consent was obtained, patients were randomly assigned to one of two groups by using an envelope system, with assignments recorded on a research log. Patients in group A received a cool damp washcloth to apply to the neck area with no scent, whereas patients in group B were given a cool damp washcloth to apply to the neck area with two drops of peppermint oil added. The bottle of peppermint oil used for this study was a 2 oz. bottle with a controlled dropper that made it easy to observe and dispense the two-drop application. The washcloth was administered to patients for 30 minutes on average, with a standard deviation of 10 minutes. After 30 minutes, the study RN returned to patients in both groups and asked them to rate their level of nausea again on the same BARF pictorial nausea scale used during the preintervention assessment.
The BARF scale was selected for this study based on its universal simplicity for the patient population. The 6-point pictorial scale depicts varying stages of nausea which correspond with possible scores of 0 (neutral), 2, 4, 6, 8, and 10 (emesis). The BARF scale has been validated for use in children, with a Spearman p correlation coefficient of 0.93 (95% confidence interval [0.91, 0.95]; p < 0.001) (Baxter et al., 2011).
Data were summarized using descriptive statistics. An independent Student’s t test was used to compare any differences among the two groups for age, pre- and postintervention BARF scores, and pre- to postintervention change scores for the BARF scale. Paired t tests were also performed for each group separately to determine whether a significant change in scores on the BARF scale occurred from the pre- to postintervention assessment. The level of significance for all tests was p < 0.05.
From March 2017 to March 2018, a total of 17,893 patients were screened on admission to the AIC. Of the patients screened, 342 rated their level of nausea as 4 or higher on the BARF scale. Seventy-nine patients met the remaining eligibility criteria and were enrolled in the study. Patient ages ranged from 18 to 79 years, with a mean age of 52.7 years (SD = 14.5). The majority of patients in both groups was female (n = 57). No statistically significant difference was found between age and gender among patients (p = 0.097). Sample characteristics are presented in Table 1.
At preintervention, both groups had similar BARF scores, with a mean score of 5.52 (SD = 1.8) among patients in group A (no scent) and a mean score of 6.11 (SD = 1.9) among patients in group B (peppermint oil) (see Table 2). Preintervention BARF scores were not statistically significant (p = 7.10). However, BARF scores at postintervention showed significant decreases from scores reported at preintervention. On average, patients in group A reported postintervention BARF scores of 2.98 (SD = 2, p < 0.001), with an average decrease in scores of 2.58 (SD = 2.5) points, whereas patients in group B reported BARF scores that decreased by 2.19 points on average (SD = 1.6, p < 0.001). Patients who received peppermint oil on their washcloth had better postintervention BARF scores than patients who received no scent, with an average decrease of 3.86 (SD = 2.2) points. Scores among patients in group B improved significantly compared to scores among patients in group A (p = 0.020) at postintervention.
The results of this study demonstrated that the use of peppermint oil on a cool damp washcloth placed on the neck of patients with chemotherapy-induced nausea was effective in relieving nausea compared to using a cool damp washcloth alone. After reviewing the literature, no previous randomized controlled trials were found that directly compared using peppermint oil on a cool damp washcloth versus a cool damp washcloth alone in patients with chemotherapy-induced nausea. To the best of the authors’ knowledge, this is the first study to compare the use of peppermint oil or no scent on a cool damp washcloth to reduce nausea in patients receiving chemotherapy. Although patients in group A (no scent) did report less nausea than at preintervention, patients in group B (peppermint oil) showed greater improvement in BARF scores. Previous studies have evaluated the efficacy of peppermint oil on nausea and vomiting in postoperative cardiac patients (Briggs et al., 2016) and in pregnant women (Joulaeerad et al., 2018). The study by Briggs et al. (2016) showed that peppermint oil inhalation was a feasible treatment that could be used for treating nausea in postoperative cardiac surgery patients, whereas the study by Joulaeerad et al. (2018) found no advantage in using inhaled peppermint oil versus a placebo in pregnant women. No previous studies were found that used inhaled peppermint oil versus a placebo to relieve chemotherapy-induced nausea, which made it difficult to review the results of this study in the context of the existing literature.
The results of this study indicated a statistically significant benefit in using peppermint oil aromatherapy with patients with chemotherapy-induced nausea. In addition, patients reported feeling relief from nausea within 30 minutes of the intervention. One unexpected finding was that only 342 patients admitted to the AIC during the study period reported a nausea score of 4 or higher on the BARF scale. This contrasted with the study team’s belief that most patients would report a higher level of chemotherapy-induced nausea on admission.
In addition, this intervention used can be easily duplicated for patients who experience chemotherapy-induced nausea in the ambulatory setting. The 2 oz. bottle of peppermint oil used for this study was cost efficient (less than $10) and lasted throughout the duration of the study. Patients are able to self-administer the cool damp washcloth with peppermint oil to their neck, which lessens time constraints on nurses.
Most patients reported a lower level of nausea within 30 minutes of application. Only one patient in the study reported that she felt that the scent of peppermint may have made her feel worse. No other patients in the study reported any adverse effects from inhaling the peppermint oil on the washcloth. Future studies could identify whether specific chemotherapy regimens are related to greater feelings of nausea to determine the overall efficacy of peppermint oil in reducing chemotherapy-induced nausea. The AIC is planning to implement the results of this study into practice by having the staff define the process and make this complimentary practice more widely available for patients experiencing nausea in the ambulatory setting.
Although outcomes were statistically significant, this study was limited based on its small overall convenience sample (N = 79). The majority of patients who were admitted to the AIC and screened for the study reported minimal to no nausea during initial assessment, which limited the size of the study sample. Because nausea is a subjective, self-reported symptom that is difficult to measure, the generalizability of the results is further limited. In addition, because this study used a convenience sample, the results cannot be generalized to varying racial, ethnic, gender, or age populations; future research should be designed to include a more diverse patient population. This study also did not compare patients’ specific chemotherapy regimens to their experience of nausea. Because patients in this study were not evaluated for emetogenic risk, future studies that factor in this risk could better compare pre- and postintervention BARF scores.
Implications for Nursing
The results of this study indicate that the use of peppermint oil on a cool damp washcloth placed on a patient’s neck is effective in decreasing self-reported levels of nausea among patients with chemotherapy-induced nausea versus a cool damp washcloth alone. This study identifies an additional option that can help to improve the experience of patients with chemotherapy-induced nausea. Offering similar aromatherapy practices with peppermint oil could be a relatively cost-effective, easy-to-use, and quick-acting intervention for patients experiencing nausea. Peppermint oil is commercially available without a prescription and provides a natural aromatherapy that can be replicated in any oncology infusion setting without a physician’s order.
The results of this study showed a statistically significant benefit to the use of peppermint oil on a cool damp washcloth in patients experiencing chemotherapy-induced nausea. However, additional research is needed to determine whether this intervention can be replicated.
The authors gratefully acknowledge Mary Gullatte, PhD, RN, ANP-BC, AOCN®, LSSYB, FAAN, and Joy Bailey, PhD, RN, for their guidance, and Melinda Higgins, PhD, for statistical assistance, as well as all the medical assistants and nurses in the Ambulatory Infusion Center for their participation.
About the Author(s)
Curlissa P. Mapp, APRN, MSN, ACNS-BC, is the director of the Magnet Program for Emory Healthcare Ambulatory Care Services and a clinical nurse specialist at the Winship Cancer Institute; Darlene Hostetler, RN, OCN®, is an advanced nurse clinician III; Jill F. Sable, MSN, RN-BC, OCN®, is a unit nurse educator and Catherine Parker, RN, MSN, OCN®, is a director, both in the Ambulatory Infusion Center at the Winship Cancer Institute; Elizabeth Gouge, RN, BS, OCN®, is an advanced nurse clinician III, Margaret Masterson, RN, OCN®, is an RN, Michelle Willis-Styles, RN, is a clinic nurse, and Claudine Fortner, RN, BSN, OCN®, is an advanced nurse clinician III, all at Emory Healthcare; and Melinda Higgins, PhD, is a research professor in the School of Nursing at Emory University, all in Atlanta, GA. The authors take full responsibility for this content. This study was funded by a J. Patrick Barnes Grant for Nursing Research and Evidence-Based Practice projects from the Daisy Foundation. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Sable can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted May 2019. Accepted October 16, 2019.)
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